During the transcatheter aortic valve replacement (TAVR) procedure in Case 1, tearing and rupture occurred below the left main coronary artery. Simulation: local (A) and full (B) views of the deformed aortic root and balloon deployment (C) show annulus tearing under the left coronary ostium due to dislodgement of calcification into vulnerable part of the aortic sinus. (For illustration purposes, the yellow geometry in our finite element models represented the aortic root, the green geometry represented native aortic leaflets, the red geometry represented calcification, and the grey geometry represented the TAV stent.)

Short-axis views of the transcatheter aortic valve (TAV) stent inside deformed native leaflets were utilized to assess the possible paravalvular leak (PVL). Case 3 demonstrates PVL following TAV replacement. The implant site of the first TAV was suboptimal, as the native leaflet insertion point was adjacent to the lower edge of the stent. A large PVL was present after the deployment of the first TAV. Subsequently, a second TAV was deployed inside of the first one to correct the defect due to suboptimal valve positioning. The valve positioning of the first TAV was replicated in the finite element model simulation, demonstrating a large PVL that was noted clinically. LCS = left coronary sinus; NCS = noncoronary sinus; RCS = right coronary sinus.

In this study, an image-based engineering analysis (Fig. 4) and prediction of transcatheter aortic valve deployment was performed using computational models reconstructed from multislice computed tomography images obtained from patients undergoing pre-TAVR evaluation. Four patients with tricuspid aortic valve stenosis subsequently received 23-mm transcatheter aortic valves (Sapien, Edwards Lifesciences Corporation, Irvine, California) (Table 1). Finite element models of the patients included aortic root, aortic leaflets, calcification, mitral-aortic intervalvular fibrosa, anterior mitral leaflet, fibrous trigones, and left ventricle. Simulations of the balloon deployment of the Sapien valve were utilized to evaluate the potential for the aforementioned complications (Online Video 1). The models presented in this paper assumed an optimal height and angulation of the stent, which is not necessarily true in all cases and is dependent, among others, on the angle between the ventricle and the aorta.

Appendix

For a supplemental video and legend, please see the online version of this article.

Footnotes

This work was supported in part by National Institutes of Health grant nos. 1R01HL104080 and 1R21HL108239, and American Heart Association pre-doctoral fellowship 13PRE14830002. Dr. Kodali has received consulting fees and honoraria grants from Edwards Lifesciences Corporation and Thubrikar Aortic Valve, Inc.; and has been a member of the scientific advisory board for Thubrikar Aortic Valve, Inc. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.